Increasing Enrollment in the Early Intervention Program

Summary

Impact Statement:

The Washington state health department conducted a Kaizen event to streamline the application process for HIV positive Washington state residents with low incomes to receive coverage. Multiple improvements were made, several target goals were exceeded, resulting in quicker access to life-saving medications and medical services. The implementation of all steps and monitoring of further improvement is in progress.

Summary:

Washington State Department of Health's (DOH's) HIV Client Services Program contracts with Evergreen Health Insurance Program (EHIP) to make premium payments on behalf of Early Intervention Program (EIP) clients and to assist these clients with navigating and understanding health insurance options in Washington State. The data exchange for shared clients between EIP and EHIP is a manual process that typically involves three EIP staff and at least two EHIP staff, who sometimes engage in duplicative steps. The delay in information exchange and likelihood of data entry errors can be costly for the program and can create access barriers for clients. The ultimate goal of the project is to increase enrollment into EHIP by April 1, 2014.

Organization that conducted the QI initiative:

Washington State DOH

Citation:

Ehri, D. Public Health Quality Improvement Exchange. Increasing Enrollment in the Early Intervention Program. Wed, 03/08/2017 - 13:02. Available at https://www.phqix.org/content/increasing-enrollment-early-intervention-program. Accessed December 7, 2023.

Background and Aim

Aim statement:

Create an efficient process for determining EIP client eligibility and subsequent enrollment into EHIP by April 1, 2014. Measures include the following: • Increase the percentage of completed mini-applications from 80% to 85% by July 1, 2013, and to 95% by January 1, 2014. • Increase the percentage of EIP applications processed within 10 business days from 10% to 35% by July 1, 2013, and to 60% by January 1, 2014. • Increase the average number of EIP applications processed per week from 120 to 150 by July 1, 2013, and to 200 by April 1, 2014, or 100% of applications received if fewer than these totals. • Decrease the staff time necessary at EIP and EHIP to monitor data exchange from 40 hours per month to 10 hours per month by April 1, 2014.

Need For The QI Initiative:

The Office of Performance and Accountability solicited projects to apply for Community of Practice for Public Health Improvement (COPPHI) funding. Program managers from EIP and EHIP realized there was a problem coordinating activities between the two programs and thought a Lean Kaizen event would be a good way to bring both parties together and work on solutions in a nonthreatening manner.

Area for Improvement:

The HIV Client Services EIP provides access to HIV antiretroviral medications, health insurance premiums, and comprehensive medical services for HIV-positive Washington State residents with income at or below 300% of the federal poverty level. In addition to an initial eligibility screening, EIP is also required to recertify clients’ eligibility every 6 months. In 2012, the program received 6,354 applications for consideration; of these, 6,267 were processed, and 4,854 clients were eligible at some point. All individuals applying to EIP for assistance for the first time or after a gap in coverage that exceeds 60 days must complete the full application. The 6-month eligibility review comprises one of two processes: a mini-renewal, in which staff have all needed information on file and complete the required form, or a standard renewal, which involves sending a partially populated form to the client for him or her to complete and return to EIP. Once EIP eligibility is awarded, EIP staff authorize a contracted vendor, EHIP, to make premium payments on behalf of EIP clients and to assist these clients with navigating their options and enrolling in health insurance. Currently, the wait time is 15–18 days from the time an application is received until eligibility is determined. In the interim, staff need to respond to calls and e-mails from clients and providers regarding eligibility, thus adding a burden to the workload. Moreover, because EIP provides access to life-saving medications, comprehensive health insurance, and medical services, any delays in eligibility could cause health consequences for the individuals these programs are designed to assist. Finally, the more money the program saves by reducing errors, keeping data updated, and avoiding overpayments, the more individuals the program can enroll and serve.

Root Cause:

The problems identified in the current process included using two different application forms (one each for EIP and EHIP), cumbersome and duplicative data-sharing requirements, and duplicating staff effort.

Planning and Execution Details

QI Implementation:

A 4-day Lean value stream mapping event was conducted in March 2013 in Tumwater, Washington. The facilitators met with the project leads and subject matter experts in four preplanning sessions to develop the charter; establish the aim statement; and determine the team members, scope of the project, and logistics. Eight staff members from EIP, six staff members from EHIP, and four facilitators participated in the event. Four clients and three case managers were engaged in a Voice of the Customer segment on the first day, during which they answered four questions: “What do you want?”, “When do you want it?,” “Why do you want it?”, and “How do you use the product, and how much do you use it?” The 14 team members then developed current and future state maps and an implementation plan to achieve the future state. The implementation plan included developing a single application for use by both EIP and EHIP (that will be pilot-tested with case managers), modifications of data-sharing requirements, and streamlined processes to reduce duplicative work between EIP and EHIP staff.

Focus activities

Disease Treatment Services:

HIV/AIDS

QI Methods:

Kaizen

Lean/Six Sigma

PDCA/PDSA Cycle (Plan, Do, Check/Study, Act)

Rapid Cycle Improvement

SDCA Cycle (Standardize-Do-Check-Act)

QI Tools:

Brainstorming

Five whys

Multi- Voting Technique

Prioritization Matrix

QI Tool Documentation:

Charter

Training

Initiative Dates:

12/1/12 to 4/1/14

Initiative Duration:

Between 18-24 months

Methods of evaluation:

Program staff began tracking both mini and full applications received by April 1, 2013. A baseline of completed full applications was established, and targets were determined accordingly (see the aim statement). Metrics initially were measured and reported on at 30, 60, and 90 days after improvements were implemented and will be measured and reported yearly thereafter.

Supplemental Materials:

Sample of materials produced

Initiative photo(s)

Report

Storyboard

Newsletter article

Supplemental Files:

Attachment	Size
Current State and Future EIP 040113.pdf	905.66 KB
Current State and Future EHIP 040313.pdf	1.13 MB
Voice of the Customer.docx	17.24 KB
EIP Launch Report Out.pptx	7.82 MB
Kaizens combined 4-1-13.docx	26.79 KB
Policy Issues-Future state assump-enablers.doc	26.5 KB
EIP Sentinel Article.docx	19.32 KB
Poster_EIP.pptx	515.81 KB
EIP Time.JPG	2.01 MB
EHIP Time.JPG	2.12 MB

Results

Measurable QI Outcomes:

The program has already exceeded its goal. The goals were set based on historical backlog. The original goal of 35% was put in place in July 2012 when results were low. The mini-application process was implemented in November 2012 and brought significant results ahead of the formal quality improvement (QI) project implementation. Between April 2013 and July 2013, 84% of full applications were completed, and 92% of mini-applications were completed.

Other QI Outcomes:

During the Lean process, the team also identified 58 ideas and categorized them into 9 themes: customer service, contract, staffing resources, training, procedures/systems, policies, IT, communications/Web, and reporting. A team and project lead were identified for each theme, and the teams were charged with developing work plans to implement the changes suggested.

Lessons Learned, Observations and Insights:

The team faced the following challenges: • Important policy decisions take time. • The manual process will remain in place until the new IT solution is implemented. • Making any additional improvements will require IT system changes. • Program-wide changes coming with the Affordable Care Act make prioritizing difficult. The team learned the following lessons: • Voice of the Customer made the team think about how changes affect customers. • Customers want the same things staff want. • All staff who play a role in the process need to be involved in finding ways to improve the process. • Decisions to change should be based on data results. • Simple improvements can have a big impact. • Looking at the process from a distance quickly shows where improvements can be made.

Future Plans:

As described previously, the results of the 4-day value stream mapping event were captured in an implementation plan, and nine teams were charged with developing implementation plans. The work of developing and implementing improvements is under way. Some changes will take much longer to institutionalize than others. Important policy decisions take time, particularly those involving receiving and sending client information via e-mail or fax. Making any additional improvements will require IT system changes to implement an electronic application. Manual processes remain in place until a new IT solution is implemented. Finally, program-wide changes coming from the Affordable Care Act make prioritizing projects and issues difficult.

Training and Preparation

Information about the Community

Information about the Health Department

QI Staff Information

Total number of Staff on QI Team:

QI team members:

Role in the Initiative:

Project lead

Name (Optional):

Elizabeth Crutsinger-Perry

Role in the Initiative:

Team member

Role in Organization:

Eligibility Specialist

Name (Optional):

Lori Delaney

Role in the Initiative:

Team member

Role in Organization:

Eligibility Specialist

Name (Optional):

Martha Grimm

Role in the Initiative:

Team member

Role in Organization:

Eligibility Specialist

Name (Optional):

Abby Gililand

Role in the Initiative:

Team member

Role in Organization:

EHIP Member, Program Manager

Name (Optional):

Mark Baker

Role in the Initiative:

Team member

Role in Organization:

EHIP Member, Senior Director of Healthcare Access (Observer)

Name (Optional):

Tabitha Jensen

Role in the Initiative:

Team member

Role in Organization:

EHIP Member, Insurance Advocate

Name (Optional):

Nora Strang

Role in the Initiative:

Team member

Role in Organization:

DOH, IT Specialist

Name (Optional):

Kevin Chandos

Role in the Initiative:

Facilitator

Role in Organization:

Quality Management Coordinator

Name (Optional):

Cher Levenson

Role in the Initiative:

Team member

Role in Organization:

Eligibility Specialist

Name (Optional):

Fran McBride

Role in the Initiative:

Team member

Role in Organization:

Eligibility Assistant

Name (Optional):

Christina James

Role in the Initiative:

Team member

Role in Organization:

Administrative Support Staff, HIV Client Services

Name (Optional):

Sheila Ichita

Role in the Initiative:

Team member

Role in Organization:

EHIP Member, Database Administrator

Name (Optional):

Yuliya Zakarenko

Role in the Initiative:

Team member

Role in Organization:

EHIP Member, Quality Analyst

Name (Optional):

Jon Choy

Role in the Initiative:

Team member

Role in Organization:

EHIP Member, Insurance Advocate

Name (Optional):

James Ludwig

Role in the Initiative:

Facilitator/Coach

Role in Organization:

Performance Management Consultant

Name (Optional):

Diana Ehri

Role in the Initiative:

Facilitator

Role in Organization:

Education and Training Coordinator

Name (Optional):

Cynthia Morrison

Role in the Initiative:

Facilitator/Coach

Role in Organization:

Director, Performance and Accountability

Name (Optional):

Susan Ramsey

Role in the Initiative:

Sponsor

Name (Optional):

Maria Courogen

Role in the Initiative:

Sponsor

Name (Optional):

Richard Aleshire

Accreditation Details

Collaborations

Contact Information of the Submitter

Submission Status:

Completed

Comments

Thanks for sharing your

Thanks for sharing your effort! You have an impressive and compelling array of improvements. Look forward to seeing how more efficiencies are gained as additional improvements are planned and implemented!

A question about the

A question about the preparation of your project: Your narrative says that the team met 4 times in the preplanning to develop the aim statement, charter, define logistics and team members. Were the 4 meetings for preplanning seen as too much to prepare? were there any concerns about that? I know there is a lot of work to do before to make the event successful, but I'm wondering how you did it. I'm starting a project and had a first meeting for 1 hour just to look at the baseline data and we had a lot of questions and issues that came up, so I know we need more meetings before the event. Just wondering how your strategy worked. Your comments/tips are appreciated! thanks,
Magaly

Magali Angeloni, DrPH, MBA
Rhode Island Department of Health's Academic Center Director
magali.angeloni@health.ri.gov

I look forward to hearing

I look forward to hearing about your IT options. Sharing data is becoming more and more necessary and increasingly challenging at the same time. For coordination of care efforts we want to share as much as possible but differing data systems, and in some cases, privacy laws make it difficult to figure out.

Margy Robinson MPH
HIV Care Services Mgr.
Multnomah County Health Dept.
Portland, OR

Link to the resource where this submission is also published:

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Increasing Enrollment in the Early Intervention Program

Summary

Background and Aim

Planning and Execution Details

Results

Training and Preparation

Information about the Community

Information about the Health Department

QI Staff Information

Accreditation Details

Collaborations

Contact Information of the Submitter

Comments

Thanks for sharing your

A question about the

I look forward to hearing

QI Spotlight

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Increasing Enrollment in the Early Intervention Program

Summary

Background and Aim

Planning and Execution Details

Results

Training and Preparation

Information about the Community

Information about the Health Department

QI Staff Information

Accreditation Details

Collaborations

Contact Information of the Submitter

Comments

QI Spotlight